Arthritis

17 August 2011

Fibromyalgia - from Natural Standard

Fibromyalgia is a complex, disabling, and chronic (long-term) condition characterized by widespread long-term pain, fatigue, and stiffness in the muscles, ligaments, and tendons, as well as multiple tender points (places on the body where slight pressure causes pain). In addition to muscular pain and fatigue, fibromyalgia may also be associated with sleep problems, depression, and an inability to think clearly.

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BACKGROUND

Fibromyalgia is a complex, disabling, and chronic (long-term) condition characterized by widespread long-term pain, fatigue, and stiffness in the muscles, ligaments, and tendons, as well as multiple tender points (places on the body where slight pressure causes pain). In addition to muscular pain and fatigue, fibromyalgia may also be associated with sleep problems, depression, and an inability to think clearly.

The word fibromyalgia comes from the Latin term for fibrous tissue (fibro) and the Greek words for muscle (myo) and pain (algia). Fibromyalgia may also be called fibromyositis, fibrositis, chronic muscle pain syndrome, psychogenic rheumatism, and tension myalgia. Although fibromyalgia is often considered an arthritis-related condition, it is not truly a form of arthritis because it does not cause inflammation or damage to the joints, muscles, or other tissues. Like arthritis, however, fibromyalgia is considered a rheumatic condition, a medical condition that impairs the joints and/or soft tissues and causes chronic pain.

The main symptom of fibromyalgia is chronic widespread musculoskeletal pain for which no alternative cause, such as tissue inflammation or damage, can be identified. Patients generally experience pain and stiffness throughout their bodies. Common additional symptoms include: fatigue, sleep disturbances, irritable bowel syndrome (IBS), headaches, facial pain, and increased sensitivity, depression, anxiety, difficulty concentrating, chest pain, numbness or tingling sensations in the hands or feet, painful menstrual periods, dizziness, as well as dry eyes, skin, or mouth. Not all people with fibromyalgia experience all associated symptoms.

The cause of fibromyalgia is unclear. Fibromyalgia is believed to be the result of central nervous system malfunction, resulting in amplification of pain transmission and detection. Researchers believe that several factors, including sleep disturbances, stress, family history of fibromyalgia, infection, injury, abnormalities in the nervous system, and changes in muscle metabolism, may lead to the development of fibromyalgia. These events, however, may or may not be present in individuals diagnosed with fibromyalgia.

The main risk factors that may predispose an individual to developing fibromyalgia or its symptoms include middle age, female gender, family history of fibromyalgia, stress, depression, rheumatic disease, and sleep disorders.

Some medical experts prefer the term fibromyalgia syndrome, arguing that fibromyalgia is not its own disease due to lacking scientific consensus about its cause. They also argue that there is a lack of abnormalities on physical examination and an absence of objective diagnostic tests. A diagnosis may be based on a pain index, the presence of key symptoms, and a measure of the severity of the symptoms. According to the American College of Rheumatology guidelines, fibromyalgia patients must have moderate-to-severe pain throughout the body for at least three months. Patients must also have at least 11 tender points (out of a total possible of 18) that are unusually sensitive when mild-to-firm pressure is applied.

Fibromyalgia is not a progressive disease and generally does not lead to other conditions or diseases. It may, however, lead to pain, depression, and lack of sleep. The problems associated with fibromyalgia may disrupt family or work relationships and performance, which may cause frustration and depression. Other conditions that may occur in fibromyalgia patients include gastroesophageal reflux disease (GERD), (IBS), temporomandibular joint (TMJ) disorder, recurrent migraine or tension-type headaches, and muscle ache.

There is no cure for fibromyalgia. However, some treatments are effective in reducing symptoms, such as medications, behavioral interventions, support groups, patient education, and exercise. In mild cases, a reduction in stress and certain lifestyle changes may be enough to manage the disease. These changes may include participation in counseling, regular exercise, physical therapy, healthy sleep habits, and stress reduction.

Scientists at the National Institutes of Health (NIH) estimate that fibromyalgia affects five million Americans age 18 years of age or older. The vast majority of fibromyalgia cases (80-90%) are women in their mid-30s to late-50s. However, men and children can also have the disorder. An estimate of the prevalence of fibromyalgia is as high as 3-5% of the population in the United States. Fibromyalgia symptoms may never completely resolve, and their intensity may vary. Although the symptoms of fibromyalgia may be hard to live with, the condition is not considered progressive or life-threatening.

RISK FACTORS

General: Although the cause of fibromyalgia is not entirely clear, there are some factors that may predispose an individual to developing fibromyalgia or its symptoms. These main risk factors include: middle age, female gender, family history of fibromyalgia, stress, rheumatic disease, and sleep disorders.

Age: Individuals between the ages of 20 and 60 are at the highest risk of developing fibromyalgia, although it may occur at any age.

Gender: Although fibromyalgia may develop in men or women, statistics indicate that women are seven times more likely to develop the condition than men. Nine of 10 fibromyalgia patients are women. An estimated 3.4% of American women have been diagnosed with fibromyalgia. Women are more likely to develop fibromyalgia during menopause than any other time. Generally, a woman's symptoms are more severe than a man's symptoms.

Genetic factors: There is some indication that genetic factors may be involved in the development of fibromyalgia. Studies have shown that individuals with family members who have fibromyalgia are at a higher risk of developing it themselves.

Psychiatric illness: While the majority of individuals with fibromyalgia report a history of psychiatric symptoms, such as depression or anxiety, many patients do not. There is no clear evidence that psychiatric illness causes fibromyalgia.

Rheumatic disease: Patients with rheumatic disease, such as rheumatoid arthritis, ankylosing spondylitis (spinal arthritis), or lupus may be more likely to develop fibromyalgia.

Sleep disorders: Patients with sleep disorders, such as restless legs syndrome or sleep apnea (pauses in breathing during sleep), may have a higher risk of developing fibromyalgia.

Stress: People who have recently experienced a stressful physical or emotional event (such as a divorce, car accident, or death of a family member) may be at a higher risk of developing fibromyalgia.

Other: Changes in weather, cold or drafty environments, infections, allergies, and hormonal fluctuations (premenstrual and menopausal states) may all contribute to the development of fibromyalgia.

CAUSES

General: The causes of fibromyalgia remain unknown. The most current hypothesis is that fibromyalgia is the result of central nervous system malfunction, resulting in amplification (increase) of pain transmission and detection. Researchers believe that several factors, including sleep disturbances, stress, family history of fibromyalgia, infection, injury, abnormalities in the nervous system, and changes in muscle metabolism, may lead to the development of fibromyalgia. These events, however, may or may not be present in individuals diagnosed with fibromyalgia.

Abnormal pain transmission: There is some evidence that fibromyalgia patients have abnormal pain transmission responses caused by defects in the central nervous system. According to the central sensitization theory, patients with fibromyalgia may have a lower pain threshold (the point at which pain begins to be felt) because of increased sensitivity in the brain to pain signals. Possible causes for this include: abnormally high levels of certain chemicals in the brain that signal pain and/ or an increased sensitivity of the brain to pain signals. Abnormal pain processing may also be responsible for symptoms experienced in several chronic pain disorders that many fibromyalgia patients also experience, including irritable bowel syndrome (IBS), temporomandibular joint disorder (TMJ), chronic low back pain, and other chronic pain disorders.

SIGNS AND SYMPTOMS

General: Symptoms of fibromyalgia may vary, depending on the weather, time of day, physical activity, and stress levels. Patients generally experience pain and stiffness throughout their bodies. Common symptoms include fatigue, sleep disturbances, irritable bowel syndrome (IBS), headaches, facial pain, and increased sensitivity. Other symptoms may include depression, difficulty concentrating, chest pain, numbness or tingling sensations in the hands or feet (paresthesia), anxiety, painful menstrual periods, dizziness, as well as dry eyes, skin, or mouth. Not all people with fibromyalgia experience all associated symptoms.

Co-existing conditions: Fibromyalgia frequently occurs in patients with psychiatric conditions such as depression and anxiety and stress-related disorders such as post-traumatic stress disorder (PTSD). Fibromyalgia also occurs more often in patients with endometriosis, lupus, osteoarthritis, or rheumatoid arthritis.

Fatigue and sleep disturbances: Fibromyalgia patients often do not feel rested, even after getting sufficient sleep. It is possible that these patients are unable to reach the deep restorative stage of sleep known as rapid eye movement (REM) sleep. Sleep and fatigue disorders associated with fibromyalgia include restless legs syndrome, sleep apnea, and chronic fatigue syndrome.

Gastroesophageal reflux disease (GERD): Gastroesophageal reflux disease (GERD), or acid reflux, occurs in roughly 40-70% of fibromyalgia patients.

Headache: Recurrent migraine or tension-type headaches are seen in about 70% of fibromyalgia patients.

Irritable bowel syndrome (IBS): Symptoms of IBS include fluctuations between constipation and diarrhea, frequent abdominal pain, abdominal gas, and nausea. Symptoms of IBS are found in roughly 40-70% of fibromyalgia patients.

Muscle ache: Patients with fibromyalgia usually experience an aching throughout their bodies. Their muscles, including those in the face, may feel like they are pulled or overworked or feel as if they are burning. Patients may wake up with body aches and stiffness.

Pain: The most common symptom experienced by fibromyalgia patients is long-term, body-wide pain and allodynia. Allodynia is pain caused by stimuli that are not normally painful and may occur in an area other than in the area being stimulated. The pain is usually in multiple locations and may be difficult to describe precisely. The pain associated with fibromyalgia is usually described as a constant dull ache, typically arising from muscles, tendons, and ligaments. The pain may also be described as radiating, gnawing, shooting or burning. It ranges from mild to severe. In some patients, the pain improves during the day and increases again during the evening, although other patients experience unrelenting pain throughout the day. The pain may increase with activity, cold or damp weather, anxiety, and stress.

Fibromyalgia is characterized by additional pain when firm pressure is applied to tender points. Tender point locations include the back of the head, between the shoulder blades, the top of the shoulders, the front sides of neck, the upper chest, the outer elbows, the upper and sides of the hips, and the inner knees.

Temporomandibular joint (TMJ) disorder: Temporomandibular joint (TMJ) disorder causes tremendous jaw-related face and head pain in one-quarter of fibromyalgia patients.

Other: Other symptoms of fibromyalgia may include premenstrual syndrome (PMS) and painful menstrual periods, chest pain, morning stiffness, cognitive or memory impairment, numbness and tingling sensations, muscle twitching, difficulty with swallowing, bowel and bladder abnormalities, swollen hands and feet, skin sensitivities, dry eyes and mouth, palpitations, dizziness, reduced exercise tolerance, and impaired coordination. Fibromyalgia patients are often sensitive to odors, loud noises, bright lights, and sometimes even the medications that they are prescribed.

DIAGNOSIS

General: Fibromyalgia is a difficult condition to diagnose. A diagnosis may be based on a pain index, the presence of key symptoms, and a measure of these symptoms and their severity. Testing may be done to rule out other conditions that may be associated with or have similar symptoms to fibromyalgia, such as cancer, cervical and low-back degenerative disease, chronic fatigue syndrome, depression, HIV infection, hypothyroidism, irritable bowel syndrome, Lyme disease, rheumatoid arthritis, and sleep disorders.

American College of Rheumatology guidelines: The American College of Rheumatology has established guidelines for diagnosing fibromyalgia. According to these guidelines, patients must have aching pain throughout the body for at least three months. Patients must also have at least 11 parts of the body (out of a total possible of 18) that are unusually sensitive when mild-to-firm pressure is applied. The tender-point sites include: fibrous tissue or muscles of the arms (elbows), buttocks, chest, knees, lower back, neck, rib cage, shoulders, and thighs.

Blood tests: While there is no lab test to confirm a diagnosis of fibromyalgia, blood may be drawn to rule out other conditions that may have similar symptoms. A test called an erythrocyte sedimentation rate (ESR) test measures the rate at which red blood cells settle to the bottom of a test tube containing blood. The ESR is increased when inflammation is present. The level of creatine kinase (a normal muscle enzyme that leaks out and is released into the bloodstream when muscle is damaged) may also be tested. Levels of creatine kinase are increased when there is widespread and ongoing destruction of muscle. Blood tests that are used to diagnose rheumatoid arthritis test for the presence of rheumatoid factor or anti-cyclic citrullinated peptide (anti-CCP) antibody in the blood. A blood test to identify autoimmune antibodies (antinuclear antibodies) is helpful in ruling out systemic lupus erythematosus (lupus).

Other: Healthcare providers may also perform other tests, including X-rays, magnetic resonance imaging (MRI), and computerized tomography (CT) scans to rule out other conditions. X-rays are most valuable for detecting abnormalities in bone and are taken to evaluate painful, deformed, or suspected abnormal areas of bone. X-rays may be helpful in showing changes that confirm a person has a certain kind of arthritis (for example, rheumatoid arthritis or osteoarthritis). X-rays do not show soft tissues such as muscles, bursae (small, fluid-filled sacs that reduce friction between moving body parts), ligaments, tendons, or nerves. CT scans and MRI give much more detail than conventional X-rays. MRI is especially valuable for imaging muscles, ligaments, and tendons.

COMPLICATIONS

General: Fibromyalgia is not a progressive disease and generally does not lead to other conditions or diseases. It may, however, lead to pain and lack of sleep. These problems may disrupt family or work relationships and performance, leading to frustration and depression. Other conditions that may occur in fibromyalgia patients include gastroesophageal reflux disease (GERD), temporomandibular joint (TMJ) disorder, recurrent migraine or tension-type headaches, and irritable bowel syndrome (IBS).

Depression: Many fibromyalgia patients suffer from depression when the condition interferes significantly with the patients' lifestyles, including causing pain. Individuals and members of their family should consult their healthcare providers if they experience feelings of sadness, low self-esteem, loss of pleasure, apathy, and difficulty functioning for two weeks or longer with no known underlying cause. These may be signs of depression.

Fatigue and sleep disturbances: Fibromyalgia patients often do not feel rested, even after getting sufficient sleep. It is possible that these patients are unable to reach the deep restorative stage of sleep known as rapid eye movement (REM) sleep. Sleep and fatigue disorders associated with fibromyalgia include: restless legs syndrome, sleep apnea, and chronic fatigue syndrome.

Gastroesophageal reflux disease (GERD): Gastroesophageal reflux disease (GERD), or acid reflux, occurs in roughly 40-70% of fibromyalgia patients.

Headache: Recurrent migraine or tension-type headaches are seen in about 70% of fibromyalgia patients.

Irritable bowel syndrome (IBS): Symptoms of IBS include fluctuations between constipation and diarrhea, frequent abdominal pain, abdominal gas, and nausea. Symptoms of IBS are found in roughly 40-70% of fibromyalgia patients.

Muscle ache: Patients with fibromyalgia usually experience an aching throughout their bodies. Their muscles, including those in the face, may feel like they are pulled or overworked or feel as if they are burning. These patients may wake up with body aches and stiffness.

Pain: The most common symptom experienced by fibromyalgia patients is long-standing, body-wide pain and allodynia. Allodynia is pain caused by stimuli that are not normally painful, and by stimuli that may occur in an area other than in the area being stimulated. The pain is usually in multiple locations and may be difficult to describe precisely. The pain associated with fibromyalgia is usually described as a constant dull ache, typically arising from muscles, tendons, and ligaments. The pain may also be described as radiating, gnawing, shooting, or burning. It ranges from mild to severe. In some patients, the pain improves during the day and increases again during the evening, although other patients experience unrelenting pain throughout the day. The pain may increase with activity, cold or damp weather, anxiety, and stress. Patients should stay in close contact with their healthcare providers to ensure that their medications are properly managing the pain; adjustments may be necessary.

Temporomandibular joint (TMJ) disorder: Temporomandibular joint (TMJ) disorder causes tremendous jaw-related face and head pain in one-quarter of fibromyalgia patients.

Other: Other complications of fibromyalgia may include: premenstrual syndrome (PMS) and painful periods, chest pain, morning stiffness, cognitive or memory impairment, numbness and tingling sensations, muscle twitching, difficulty with swallowing, bowel and bladder abnormalities, swollen hands and feet, skin sensitivities, dry eyes and mouth, palpitations, dizziness, reduced exercise tolerance, and impaired coordination. Fibromyalgia patients are often sensitive to odors, loud noises, bright lights, and sometimes even the medications they are prescribed.

TREATMENT

General: There is no cure for fibromyalgia. However, some treatments are effective in reducing symptoms, such as medications, behavioral interventions, support groups, patient education, and exercise. In mild cases, a reduction in stress and certain lifestyle changes may be enough to manage the disease. These changes may include: participation in counseling, regular exercise, physical therapy, healthy sleep habits, and stress reduction.

The management of fibromyalgia usually requires a multi-disciplinary approach combining pharmacological and nonpharmacological modalities (methods of treatment). It is important to find a doctor who is knowledgeable about fibromyalgia before beginning treatment. In addition to a family physician, medical specialists may be consulted, such as a rheumatologist (specializes in conditions that affect the joints or soft tissues), a physical therapist, a pain specialist, and others.

U.S. Food and Drug Administration (FDA) has approved three drugs for the management of fibromyalgia: duloxetine (Cymbalta©), milnacipran (Savella©), and pregabalin (Lyrica©). Other types of medications may also be prescribed to manage symptoms or co-existing conditions. Such drugs may include: antidepressants, anti-seizure drugs, benzodiazepines, muscle relaxants, and pain relievers. In order to properly manage pain, individuals should take their medications as prescribed by their healthcare providers. Patients should also tell their healthcare providers if they are taking any herbs, dietary supplements, or other drugs (prescription or over-the-counter), because they may interfere with treatment.

Antidepressants: Many individuals with fibromyalgia also suffer from depression. There is evidence that antidepressants in low doses may decrease depression, relax craniofacial and skeletal muscles, improve sleep quality, and release pain-killing endorphins (compounds). Side effects of antidepressant medications include: drowsiness, fatigue (excessive tiredness), reduced sex drive, increased risk of suicide, increased blood pressure, constipation, dry mouth, and blurred vision.

Tricyclic antidepressants: When taken at bedtime in dosages lower than those used to treat depression, tricyclic antidepressants may help promote restorative sleep in people with fibromyalgia. They also may relax painful muscles and heighten the effects of the body's natural pain-killing substances called endorphins. Examples of tricyclic medications used to treat fibromyalgia include: amitriptyline hydrochloride (Elavil©, Endep©), cyclobenzaprine (Cycloflex©, Flexeril©, Flexiban©), doxepin (Adapin©, Sinequan©), and nortriptyline (Aventyl©, Pamelor©). Both amitriptyline and cyclobenzaprine have been proven useful for the treatment of fibromyalgia.

Selective serotonin reuptake inhibitors (SSRIs): Another class of antidepressant that may be prescribed is known as selective serotonin reuptake inhibitors (SSRIs). They are usually prescribed for fibromyalgia patients in lower dosages than are used to treat depression. By promoting the release of serotonin, these drugs may reduce fatigue and some other symptoms associated with fibromyalgia. The group of SSRIs includes fluoxetine (Prozac©), paroxetine (Paxil©), and sertraline (Zoloft©). Newer SSRIs such as citalopram (Celexa©) or escitalopram (Lexapro©) do not seem to work as well for pain as the older SSRIs. There is evidence that a combination therapy of the tricyclic amitriptyline and the SSRI fluoxetine resulted in greater improvements in the study participants' fibromyalgia symptoms than either drug alone. However, this combination therapy is associated with an increased risk of serotonin syndrome.

Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs are a newer class of antidepressants that raise levels of both serotonin and norepinephrine. Examples of these medications include: venlafaxine (Effexor©), duloxetine (Cymbalta©), and milnacipran (Savella©). In general, these drugs work better for pain than SSRIs.

Anti-seizure drugs: Medications designed to treat epilepsy are often useful in reducing certain types of pain. Gabapentin (Neurontin©) is sometimes helpful in reducing fibromyalgia symptoms. Patients with fibromyalgia may take an anti-seizure medication, called pregabalin (Lyrica©). Although this medication is primarily used to prevent seizures, the FDA has also approved the medication as a treatment for fibromyalgia. Pregabalin has been shown to reduce pain caused by fibromyalgia. Side effects may include: dizziness, sleepiness, difficulty concentrating, blurred vision, weight gain, dry mouth, and swelling in the hands and feet; alcohol should be avoided while taking this medication.

Benzodiazepines: Benzodiazepines are sometimes used in fibromyalgia patients to relax tense, painful muscles and promote a deep sleep pattern. Benzodiazepines also may relieve the symptoms of restless legs syndrome. Doctors usually prescribe benzodiazepines only for people who have not responded to other therapies because of the potential for addiction. Benzodiazepines include clonazepam (Klonopin©) and diazepam (Valium©).

Cool compress or ice pack: Applying a cool compress or ice pack to the affected joint during a painful flare-up may help reduce swelling and pain caused by a rheumatic disease.

Counseling: In cognitive behavioral therapy, techniques for dealing with stressful situations are learned and practiced. Individual or group therapy may be used. Support groups are available for patients with fibromyalgia.

Diet: Eating a well-balanced diet and avoiding caffeine may reduce the severity of fibromyalgia symptoms, including problems sleeping.

Drugs: Although other medications may be prescribed to manage symptoms associated with fibromyalgia, only three medications, duloxetine (Cymbalta©), milnacipran (Savella©), and pregabalin (Lyrica©), have been approved by the FDA for the treatment of fibromyalgia. Cymbalta© was originally developed for and is still used to treat depression. Lyrica© is an anti-seizure medication developed to treat neuropathic pain (chronic pain caused by damage to the nervous system). Savella© is not approved for any condition other than fibromyalgia.

Exercise/physical therapy: Studies have shown that fibromyalgia symptoms may be relieved by aerobic exercise. Patients should consult with a physician before beginning an exercise program. A physical therapist may be helpful in deciding those exercises that are most appropriate. Specific exercises may help restore muscle balance and reduce pain. Stretching techniques may also be recommended.

Heat: Applying a hot pack to affected joints may help reduce pain, relax muscles, and increase blood flow to the joint. It may also be an effective treatment before exercise. Alternatively, patients may take a hot shower or bath before exercise to help reduce pain.

Irritable bowel syndrome (IBS) management: Symptoms of IBS are found in roughly 40-70% of fibromyalgia patients. To manage this symptom, fiber supplements or laxatives to relieve constipation or medications such as diphenoxylate/atropine (Lotomil©) or loperamide (Imodium©) to relieve diarrhea may be used. A prescription medication called alosetron (Lotronex©) is approved for the treatment of severe IBS with diarrhea that does not respond to other treatment. Another drug, lubiprostone (Amitiza©), is approved for the treatment of IBS with constipation.

Muscle relaxants: Muscle relaxants, such as cyclobenzaprine (Flexeril©), may help reduce muscle pain and spasms associated with fibromyalgia. Patients usually take these medications by mouth before sleep. Muscle relaxants should only be taken short-term. The most common side effect of muscle relaxants is sedation. Patients should not drive or operate machinery or consume alcohol while taking muscle relaxants.

Pain relievers: Over-the-counter pain relievers used in the treatment of fibromyalgia include acetaminophen (Tylenol©). However, its effectiveness varies. Prescription pain relievers, including tramadol (Ultram©), have also been used with or without acetaminophen. Although tramadol does not reduce swelling, it has fewer side effects than nonsteroidal anti-inflammatory drugs (NSAIDs). It is generally taken as a short-term treatment to reduce symptoms of flare-ups. It is not used long-term due to the risk of addiction.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil©, Motrin©, and others) or naproxen sodium (Aleve©, and others), are sometimes used in conjunction with other medications to manage pain associated with fibromyalgia. Commonly prescribed NSAIDs include diclofenac (Cataflam© or Voltaren©), nabumetone (Relafen©), or short-term ketoprofen (Orudis©). NSAIDs are generally taken long term to manage symptoms. NSAIDs treat inflammation. Although inflammation is not a symptom of fibromyalgia, NSAIDs also relieve pain and may help ease the muscle aches of fibromyalgia. They may also relieve menstrual cramps and headaches associated with fibromyalgia. The frequency and severity of side effects vary depending on the specific NSAID used. The most common side effects include: nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. The most serious side effects include: kidney failure, liver failure, gastrointestinal ulcers, heart-related problems, and prolonged bleeding after an injury or surgery. About 15% of patients who receive long-term NSAID treatment develop ulcers (open sores) in the stomach or duodenum.

For fibromyalgia patients with severe pain, narcotic medications may be prescribed. However, there is no solid evidence showing that narcotics actually work to treat the chronic pain of fibromyalgia in most people. Narcotic pain relievers are only used short-term to treat flare-ups. Common side effects include: constipation, drowsiness, dry mouth, and difficulty urinating. Narcotic pain relievers should be used cautiously because patients may become addicted to them.

Sleep: Since patients with sleep disorders (i.e., restless legs syndrome, sleep apnea) may have a higher risk of developing fibromyalgia, patient-specific therapies may be recommended to improve the quality of sleep. These may include medications (such as amitriptyline) and/or machines to assist in breathing during the night.

Stress reduction: Since physical or emotional trauma may trigger fibromyalgia, reducing stress and improving coping skills may also help reduce painful symptoms. Approaches may include using medications (such as sertraline (Zoloft©) or practicing relaxing activities (such as yoga or meditation).

INTEGRATIVE THERAPIES

Good scientific evidence:

5-HTP: 5-HTP is the precursor of the neurotransmitter serotonin. It is obtained commercially from the seeds of the plant Griffonia simplicifolia. There is a small amount of research evaluating the use of 5-HTP for fibromyalgia, and early evidence suggests that 5-HTP may reduce the number of tender points, anxiety, and intensity of pain and may improve sleep, fatigue, and morning stiffness.

5-HTP may cause drug interaction with medications such as antidepressants and sleep medicines. A potentially life-threatening condition called serotonin syndrome could occur in patients who take 5-HTP in combination with antidepressants. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Acupuncture: There is evidence from several studies suggesting acupuncture may help with pain relief in fibromyalgia. More high quality studies would help to confirm these study results.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders, or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or those with a history of seizures.

Chlorella: A randomized controlled trial and one case series indicate that chlorella may reduce the tenderness associated with fibromyalgia's tender points. Although the results are promising, more high-quality studies are needed to confirm these studies' findings.

Avoid in patients with known allergy/hypersensitivity to chlorella, its constituents, mold, or members of the Oocystaceae family. Use cautiously in patients with hypotension, altered immune function, cancer, or those taking antihypertensives or immunomodulators. Use cautiously in patients with photosensitivity, taking photosensitizers, or exposed to the sun. Avoid long-term supplementation or with manganese supplementation. Avoid in patients using warfarin or other anticoagulant therapy.

Trigger point therapy: There have been several studies that addressed the therapeutic potential of trigger point therapy (the practice of compressing small areas or trigger points in a muscle from which pain is believed to radiate in that area or in unrelated areas). The results of the higher-quality studies show slight, albeit not significant, improvement of myofascial pain. Many of the medium-quality studies illustrate more pronounced improvement and statistical differences. Overall, the studies indicate that trigger point therapy may be effective for myofascial pain. However, future studies need to be performed before any definitive conclusions can be drawn.

Use cautiously with local or systemic infection, anticoagulation or bleeding disorders, or acute muscle trauma. Avoid aspirin ingestion within three days of injection. Avoid with extreme fear of needles, large bruises, phlebitis, varicose veins, undiagnosed lumps, or open wounds. Avoid if allergic to anesthetic agents (mainly caused by aminoester agents). Use cautiously during pregnancy.

Unclear or conflicting scientific evidence:

Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. Further research is needed to determine if chiropractic therapy is an effective treatment for hip pain, osteoarthritis, fibromyalgia, or temporomandibular joint (TMJ) disorders.

Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis (the slipping of a disc in the spine over the one beneath it), or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding, due to a lack of scientific data. Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, or migraines. Use cautiously with the risk of tumors or cancers.

Comfrey: A comfrey-containing cream has been applied on the skin to reduce pain associated with myalgia (muscle pain). Improvements in pain at rest and in motion were noted. Further studies are required before a firm recommendation can be made.

Avoid if allergic/hypersensitive to comfrey, its constituents, or members of the Boraginaceae family. Avoid oral comfrey, due to hepatotoxic and carcinogenic pyrrolizidine alkaloids; oral use has caused death. Avoid topical comfrey on broken skin, due to hepatotoxic and carcinogenic pyrrolizidine alkaloids. Avoid topical comfrey in individuals with or at risk for hepatic disorders, cancer, or immune disorders. Use topical creams containing comfrey cautiously if taking anti-inflammatory medications or cytochrome P450 3A4-inducing agents. Use extreme caution when using topical creams containing comfrey for extended periods. Avoid if pregnant or breastfeeding.

Dehydroepiandrosterone (DHEA): Preliminary evidence suggests that DHEA (dehydroepiandrosterone) may not offer benefit to individuals with rheumatoid arthritis or fibromyalgia. Further research is needed in this area.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Feldenkrais Method©: The Feldenkrais Method© uses gentle touch, movement, and directed attention to increase self-awareness and body movement. In early studies of patients with nonspecific musculoskeletal disorders, Body Awareness Therapy© and Feldenkrais seemed to improve health-related quality of life. The Feldenkrais Method© is popularly considered a useful treatment for chronic pain. However, clinical evidence of the efficacy of Feldenkrais in fibromyalgia is limited. There is currently a lack of available scientific studies or reports of safety of the Feldenkrais Method©.

Guided imagery: Guided imagery uses imagination to heal the body. Cognitive-behavioral interventions for pain may be an effective adjunct to standard pharmacologic interventions for pain in patients with osteoarthritis or juvenile rheumatoid arthritis. Initial research for fibromyalgia also suggests possible reductions in pain and improvements in functioning. Further research is needed to confirm these results.

Guided imagery is usually intended to supplement medical care, not to replace it, and should not be relied on as the sole therapy for a medical problem. Contact a qualified healthcare provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety, or emotional upset because imagery may trigger these symptoms. Speak with a qualified healthcare provider before practicing guided imagery if feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse.

Hypnosis, hypnotherapy: Although multiple trials report diminished pain levels or requirements for pain-relieving medications after hypnotherapy (techniques that bypass the conscious mind), there is limited research for rheumatoid arthritis pain specifically. Other signs of rheumatoid arthritis, such as joint mobility or blood tests for rheumatoid factor, have not been adequately assessed. There is inconclusive evidence from preliminary research regarding use of hypnotherapy for fibromyalgia. Additional study is needed before a firm conclusion can be drawn.

Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder, or dissociative disorders. Use cautiously with seizure disorders.

Magnet therapy: Initial evidence has failed to show improvements in pain from rheumatoid arthritis or osteoarthritis with the use of magnet therapy (using magnets to produce static magnetic fields in the body for possible health benefits). However, due to the methodological weaknesses of this research, the conclusions cannot be considered definitive. The effectiveness of magnet therapy as an additive treatment for fibromyalgia has been assessed in preliminary studies (including the use of magnetic sleep pads). Results of recent research suggest that magnetic fields may not be helpful for this condition. Better study is needed before a firm conclusion can be drawn.

Avoid with implantable medical devices like heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.

Massage: Massage may be of benefit for rheumatoid arthritis, but there is currently not enough scientific data on which to base a strong conclusion for this indication. A small number of studies report that massage may improve pain, depression, and quality of life in fibromyalgia patients. Early evidence suggests that massage may reduce the number and intensity of painful trigger points. More studies are needed regarding use of massage for myofascial pain.

Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin©). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

Meditation: It has been suggested that mindfulness meditation may help improve symptoms in patients with fibromyalgia. Better quality research is needed before a conclusion can be formed.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professionals before starting a program of meditation and should explore how meditation may or may not fit with their current treatment plans. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnose or treat the condition with more proven techniques or therapies. Meditation should not be used as the sole approach to illnesses.

Physical therapy: Several studies have indicated that treatment of rheumatoid arthritis with physical therapy may help improve morning stiffness and grip strength. Some experts have suggested a long-term, high-intensity exercise program. Beneficial effects may last up to one year. Despite promising early evidence, better-designed studies are needed to draw a firm conclusion. More research is also needed to determine if physical therapy is an effective treatment for frozen shoulder, hip pain, joint problems (including rotator cuff and sacroiliac joint dysfunction), or osteoarthritis.

Early research indicates that a self-management based program of pool exercises and education may improve the quality of life of patients with fibromyalgia and their satisfaction with treatment. In one study, physical therapy did not show better effects when compared with hypnotherapy. Additional study is needed to make a firm recommendation for use of physical therapy for myofascial pain.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Qi gong: There is mixed evidence regarding the usefulness of Qi gong (a Chinese system similar to meditation or yoga, of physical and mental training for health, martial arts, and emotional well-being) in treating fibromyalgia. More research is needed before a conclusion can be made.

Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders.

Relaxation therapy: Limited preliminary research reports that muscle relaxation training may improve function and well being in patients with rheumatoid arthritis. Additional research is necessary before a conclusion can be reached. In a randomized study of patients with osteoarthritis pain, Jacobson relaxation was reported to lower the level of subjective pain over time. The study concluded that relaxation might be effective in reducing the amount of analgesic medication taken by participants. Further well-designed research is needed to confirm these results.

Relaxation has been reported to reduce fibromyalgia pain. However, results from other studies are conflicting, and therefore further research is needed before a clear recommendation can be made.

Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, and then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.

S-adenosyl-methionine (SAMe): Since fibromyalgia is characterized by chronic pain and depressive symptoms, there is an increased interest in studying S-adenosyl-methionine (SAMe) for this indication. Current available evidence, however, does not appear to show any benefit of SAMe over placebo in reducing the number of tender points and in alleviating depression. Additional study is needed to confirm these findings.

Avoid if allergic or hypersensitive to SAMe. Use cautiously with diabetes and anxiety disorders, or women in their third trimester of pregnancy. Avoid with bipolar disorder. Avoid during first trimester of pregnancy or if breastfeeding.

Tai chi: There is not enough scientific evidence showing that tai chi (a system of body movements and positions that aim to address the body and mind as an interconnected system) reduces rheumatoid arthritis symptoms, although tai chi may help improve range of motion of the lower extremities. A small trial in women with osteoarthritis reported that treatment with tai chi significantly decreased pain and stiffness compared with a sedentary lifestyle. Women in the tai chi group also reported fewer perceptions of difficulties in physical functioning. More research is needed in this area. Tai chi may also aid quality of life in fibromyalgia patients, but additional study is needed to make a strong recommendation.

Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

TENS (transcutaneous electrical nerve stimulation): Preliminary studies of transcutaneous electrical nerve stimulation (TENS) in patients with rheumatoid arthritis, fibromyalgia, and temporomandibular joint pain (TMJ) report improvements in joint function and pain. However, most research is not well designed or reported, and better studies are needed before a clear conclusion can be reached.

Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

Therapeutic touch: Preliminary research suggests that therapeutic touch (an adaptation of several healing traditions in which the practitioner holds his/her hands above the patient's body to detect the patient's energy field and correct any perceived imbalances) may be an effective treatment option in relieving pain in patients with fibromyalgia. Further research is needed before a recommendation can be made.

Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.

Fair negative scientific evidence:

Dehydroepiandrosterone (DHEA): Preliminary evidence suggests that DHEA (dehydroepiandrosterone) may not offer benefit to individuals with rheumatoid arthritis or fibromyalgia. Further research is needed in this area.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

PREVENTION

General: There is currently no known method of prevention for fibromyalgia. Patients should take their medications exactly as prescribed and visit their healthcare providers regularly to help prevent complications and ensure that symptoms are properly managed. Lifestyle modifications may prevent symptoms associated with fibromyalgia. Examples include dietary restrictions, regular exercise, occupational changes, setting realistic expectations, getting proper amounts of sleep, and reducing stress levels.

Diet: Although no specific diet has been proven to influence fibromyalgia, food allergies may be a contributing factor in fibromyalgia development. It may be advisable to eliminate potential food allergens, including dairy (milk, cheese, and sour cream), eggs, nuts, shellfish, wheat (gluten), corn, preservatives, and food additives (such as dyes and fillers). If the individual is allergic to dairy products, calcium supplements are recommended. Experts recommend avoiding refined foods such as white breads, pastas, and sugar. Doughnuts, pastries, bread, candy, soft drinks, and foods with high sugar or caffeine content may all contribute to worsening symptoms of fibromyalgia.

Exercise: Studies have shown that fibromyalgia symptoms may be relieved by aerobic exercise. Patients should consult with a physician before beginning an exercise program. A physical therapist may be helpful in deciding exercises that are the most appropriate. Specific exercises may help restore muscle balance and may reduce pain. Stretching techniques may also be recommended.

Occupational changes: Fibromyalgia patients may need to work fewer hours or switch to a less physically demanding or less stressful job in order to manage their disease. Occupational therapists may make suggestions that may help.

Realistic expectations: It is necessary for fibromyalgia patients to pace themselves and not try to overdo activities. Stress may trigger symptoms associated with fibromyalgia.

Sleep: Since patients with sleep disorders (i.e., restless legs syndrome, sleep apnea) may have a higher risk of developing fibromyalgia, patient-specific therapies may be recommended to improve the quality of sleep. This may include medications (such as amitriptyline) and/or machines to assist in breathing during the night.

Stress reduction: Since physical or emotional trauma may trigger fibromyalgia, reducing stress and improving coping skills may also help reduce painful symptoms. Approaches may include using medications or practicing relaxing activities, such as yoga or meditation.

AUTHOR INFORMATION

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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Copyright © 2011 Natural Standard (www.naturalstandard.com)
 

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Professor Asgar Ali Kalla completed his MBChB (Bachelor of Medicine and Bachelor of Surgery) degree in 1975 at the University of Cape Town and his FRCP in 2003 in London. Professor Ali Kalla is the Isaac Albow Chair of Rheumatology at the University of Cape Town and also the Head of Division of Rheumatology at Groote Schuur Hospital. He has participated in a number of clinical trials for rheumatology and is active in community outreach. Prof Ali Kalla is an expert in Arthritis for Health24.

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